Deported in a Coma, Saved Back in U.S.

Soon after Antonio Torres, a husky 19-year-old farmworker, suffered catastrophic injuries in a car accident last June, a Phoenix hospital began making plans for his repatriation to Mexico. Mr. Torres was comatose and connected to a ventilator. He was also a legal immigrant whose family lives and works in the purple alfalfa fields of this southwestern town. But he was uninsured. So the hospital disregarded the strenuous objections of his grief-stricken parents and sent Mr. Torres on a four-hour journey over the California border into Mexicali.

For days, Mr. Torres languished in a busy emergency room there, but his parents, Jesús and Gloria Torres, were not about to give up on him. Although many uninsured immigrants have been repatriated by American hospitals, few have seen their journey take the U-turn that the Torreses engineered for their son. They found a hospital in California willing to treat him, loaded him into a donated ambulance and drove him back into the United States as a potentially deadly infection raged through his system.

By summer’s end, despite the grimmest of prognoses from the hospital in Phoenix, Mr. Torres had not only survived but thrived. Newly discharged from rehabilitation in California, he was haltingly walking, talking and, hoisting his cane to his shoulder like a rifle, performing a silent, comic, effortful imitation of a marching soldier.

“In Arizona, apparently, they see us as beasts of burden that can be dumped back over the border when we have outlived our usefulness,” the elder Mr. Torres, who is 47, said in Spanish. “But we outwitted them. We were not going to let our son die. And look at him now!”

Antonio Torres’s experience sharply illustrates the haphazard way in which the American health care system handles cases involving uninsured immigrants who are gravely injured or seriously ill. Whether these patients receive sustained care in this country or are privately deported by a hospital depends on what emergency room they initially visit.

There is only limited federal financing for these fragile patients, and no governmental oversight of what happens to them. Instead, it is left to individual hospitals, many of whom see themselves as stranded at the crossroads of a failed immigration policy and a failed health care system, to cut through a thicket of financial, legal and ethical concerns.

That creates a burden. “It’s a killer,” said Brian Conway, spokesman for the Greater New York Hospital Association. But it also establishes the potential for neglectful and unethical if not illegal behavior by hospitals.

“The opportunity to turn your back is there,” said Dr. Stephen Larson, a migrant health expert and physician at the Hospital of the University of Pennsylvania. “You’re given an out by there not being formal regulations. The question is whether or not litigation, or prosecution, catches up and hospitals start to be held liable.”

In October, the California Medical Association, responding to an article in The New York Times about the medical deportation of a brain-injured Guatemalan, passed a resolution opposing the forced repatriation of patients. The American Medical Association is to take up the matter on Sunday at a national meeting in Orlando.

“While we empathize with hospitals that must provide uncompensated care to undocumented immigrants,” said Dr. Robert Margolin, a trustee of the California association, “we overwhelmingly oppose the practice of repatriating patients without their consent.”

An examination by The Times of cases across the country involving seriously injured and ill immigrants shows patients at the mercy of hospitals and hospitals at the mercy of a system that provides neither compensation nor guidance. Taken together, the cases reveal a playbook of improvised responses, from aggressive to compassionate.

In the case of Elliott Bustamante, a hospital in Tucson moved speedily, and ultimately unsuccessfully, to transfer a sickly infant to Mexico, ignoring the mother’s opposition and the fact that Elliott was an American citizen born with Down syndrome and a heart problem at that very hospital.

In the case of Kong Fong Yu, in contrast, a Manhattan hospital has proceeded less decisively, keeping Mr. Yu, a stroke victim, as a boarder for 18 months now as it grapples with whether to send him back to China or to subsidize him in a nursing home indefinitely.

And in the case of Darwin Castro, an illegal immigrant from Honduras, an Oklahoma City hospital forwent repatriation yet discharged Mr. Castro, a brain-injured patient who needed 24-hour care, to a young relative who also happened to be an illegal immigrant, living in the shadows and ill-equipped to care for him.

The Dilemma

Hospitals consider these fragile patients to be a vexing challenge. Theirs are protracted, expensive cases that force hospitals to make fateful decisions or assume long-term responsibility for needy immigrants who are, essentially, left at their doorsteps.

The two American hospitals treating Antonio Torres approached his case from distinctly different perspectives. St. Joseph’s in Phoenix, with a focus on keeping down the rising cost of uncompensated care, repatriates about eight uninsured patients a month.

“We’re trying to be good stewards of the resources we have,” said Sister Margaret McBride, a hospital vice president. “We’re trying to make sure that the acute-care hospital is available for individuals who need acute care. We can’t keep someone forever.”

By contrast, the other hospital, El Centro Regional Medical Center in California, said it never sends an immigrant over the border. “We don’t export patients,” said David R. Green, its chief executive. “I can understand the frustrations of other hospitals, but the flip side is the human being element.”

Hospitals are required to screen and treat all those who arrive at their emergency rooms. But they receive only partial compensation for illegal immigrants, through emergency Medicaid and, for the last few years, through Section 1011 of the Medicare Modernization Act of 2003, a program that expired in October. That partial coverage ends when the patient is stabilized.

But hospitals are also required to discharge safely patients who need continuing care, leading to their quandary: they generally cannot find nursing homes to accept illegal immigrants, or legal ones with less than five years’ residency, because long-term care is not covered by emergency Medicaid.

Some states and localities provide their own long-term care coverage for uninsured immigrants, and those exceptions demonstrate the demand. In California, the Medi-Cal program spent about $20 million on about 460 patients last year. In New York City, illegal immigrants occupy about a fifth of the 1,389 beds in the public nursing home on Roosevelt Island.

Hospitals have limited options in discharging immigrant patients who need continuing care: keeping them indefinitely, with or without providing rehabilitation; finding them charity beds or subsidizing them at nursing homes; sending them home to relatives; or repatriating them.

“We have to be very, very creative,” said Cara Pacione, director of social work at Mount Sinai Hospital in Chicago.

Foreign consular officials say that areas with longstanding immigrant populations tend to handle such patients more humanely — with the exception of Arizona, where hostility toward illegal immigrants is high and state financing for their care is low.

“We put an asterisk by Arizona,” said a Mexican diplomat in Washington.

Hospitals need consulates’ assistance in finding relatives and health care options in patients’ homelands as well as in obtaining travel documents. The relationship is complicated and often contentious, as expressed bluntly by Alan Kelly, vice president of Scottsdale Healthcare in Arizona.

He described the situation with illegal immigrant patients as he sees it: “Somebody falls out of a walnut tree. They show up in our Trauma One center. We don’t have any problem with treating or stabilizing them. It’s the humane thing to do. That’s not where the costs run up. The costs run up after they’re moved out of the trauma unit into a regular bed. Nobody, no nursing home, wants to take them. Then, it’s like, ‘Mexican government, take responsibility for your own citizens!’ But you play games with them. They turn away. They basically say, ‘No habla.’ ”

Mexican officials, unsurprisingly, see it differently. “We cooperate with the families, not with the hospital,” Jorge Solchaga, a Mexican consular official in Phoenix, said. “Our principal objective is to help our compatriots.”

Still, Mr. Solchaga said that his office worked collaboratively with hospitals and oversaw 80 medical repatriations from Phoenix to Mexico in 2007.

An Infant at Risk

Elliott Bustamante was born at University Medical Center in Tucson on March 14, 2007, with Down syndrome and a heart defect. Two days later, when he was in neonatal intensive care, the hospital made arrangements to transfer him to a hospital in Mexico.

The fact that he was a United States citizen was immaterial, the hospital’s spokeswoman, Katie Riley, said. The hospital’s policy is to transfer patients to their “community of residence” for continuing care, Ms. Riley said. And Elliott’s parents, the hospital believed, were residents of Mexico, as indicated by their Mexican driver’s licenses. Also, the hospital said, the mother initially told a social worker, through an interpreter, that she was visiting Tucson when she went into labor. Therefore, the hospital said, it was in the baby’s interest, from a continuity of care perspective, to move him to Mexico.

But Gricelda Mejía Medehuari, Elliott’s mother, said that either the hospital misunderstood her or that she failed to express herself accurately.

Ms. Medehuari said that she had been living in Tucson for about a year prior to Elliott’s birth, and that her husband had been working construction there for two years. The hospital also said that Ms. Medehuari initially agreed to her baby’s transfer, then “equivocated.”

Ms. Medehuari said she was pressured: “We were so scared. They said we had no rights, the baby neither. They said they would send the baby with or without me. When Elliott was two weeks, they told me to gather my things because the baby was leaving in 15 minutes with a lady. It was very ugly. We contacted the Mexican consulate. They got us a lawyer.”

The lawyer, Fernando Gaxiola, asked the hospital to delay sending the baby across the border, and faxed a letter saying that he would be seeking court protection to avert “the abduction of my client under the guise of medical care.” A hospital lawyer, he said, told him that it was too late, that the baby was already heading to the airport.

Mr. Gaxiola summoned the police, who called the hospital, which ended up switching gears and bringing the baby back to University Medical Center.

Nine days later, the hospital asked a judge to order Elliott’s parents to consent to his transfer to Mexico. His parents had made no arrangements to pay $28,000 in hospital charges or to transfer their child, the hospital said. Legally, the hospital argued, the baby could be considered to be trespassing.

Eventually, after the Arizona Medicaid system approved Elliott for coverage, University Medical Center was reimbursed for the baby’s care and dropped its effort to send him to Mexico. “The medical pretext for the transfer disappeared once they found the money,” Mr. Gaxiola said.

Ms. Riley, the University Medical Center spokeswoman, said Elliott’s case “is not representative of U.M.C.’s long history of successful medical transfers of patients both to and from northern Mexico, but it does underline the complex dilemmas that border hospitals face every day.”

New Yorker in Limbo

Hospitals in New York City face equally complex dilemmas, with the added dimension of a more diverse immigrant population and prospective repatriations to Africa and Asia. The case of Kong Fong Yu has stymied a community hospital in Lower Manhattan.

Mr. Yu, 53, suffered a stroke on May 14, 2007. He awoke with slurred speech and then collapsed on his bathroom floor. By the time he arrived at New York Downtown Hospital, it was too late to try to reverse damage to the brain, the hospital said in court papers.

The hospital admitted Mr. Yu for tests and to regulate his high blood pressure, which he had been treating with Chinese herbs. Almost immediately, Mr. Yu was considered medically stable and ready for discharge to a skilled nursing home. But since he was uninsured and ineligible for Medicaid, no nursing home would take him. He had no relatives in the United States.

So he stayed, and stayed. And he was not the only one. Jeffrey Menkes, the hospital’s president, said Downtown housed a few uninsured immigrants like Mr. Yu at any given moment, which costs the hospital $1.5 million to $2 million annually. It also costs patients like Mr. Yu the chance to receive the intensive rehabilitation that they need.

Mr. Yu, according to a hospital document, can “perform some independent activities of daily living, including turning in bed and feeding himself.” But he is “dependent on staff for other daily necessities” and suffers from “limited cognition and limited independent judgment.”

One day last summer, he lay in his fourth floor bed watching a soundless “Clifford the Big Red Dog” cartoon with his roommate, a tiny, elderly Chinese man who has been boarding at the hospital for years.

Mr. Yu said that he entered the United States legally 11 years ago and then overstayed his visa to work “on the black market” as a cook. Speaking in Mandarin that was translated by a hospital employee, Mr. Yu said he was grateful to Downtown. “American hospitals are very humane,” he said. “I have no money. This hospital is giving me food, a bed and care.”

But the hospital does not want him to stay indefinitely. Last winter, Mr. Menkes said, at a moment when he had patients “stacked up in the emergency room,” he realized that he needed to find a way to discharge patients like Mr. Yu. Shortly thereafter, the hospital went to court to get a guardian appointed.

“He is utilizing valuable hospital resources,” the hospital said, “when the hospital is overburdened and cannot and is not equipped to provide rehabilitation or long-term care.”

When Katherine B. Huang, a Chinese-American lawyer, was appointed his guardian last spring, the hospital planned to transfer Mr. Yu to a Brooklyn nursing home and support his stay. Ms. Huang sought to clarify what the hospital was promising.

“I said, ‘You’re going to pay for him for the rest of his life?’ ” she recounted. “I said, ‘Does your negotiated rate with the nursing home cover his rehabilitation and health care needs, too? What about burial costs?’ I mean, you have to think this all through. They told me the lawyers were hammering it out.”

But the hospital later changed course.

In late September, Mr. Yu entered the courtroom of New York State Supreme Court Judge Lottie E. Wilkins on a taxi-yellow gurney. Dressed in a hospital gown, he smoothed his thin hair and saluted the judge in English. Squeezing a small rubber ball for exercise, he was then wheeled behind closed doors, accompanied by his guardian, for what Judge Wilkins called a status conference, closed to the news media.

No record was made of the proceeding. But the guardian said that she learned then that the hospital was contemplating sending him back to his relatives in China.

“All of a sudden, it became, ‘Great, the family wants him back,’ after the hospital repeatedly told me the family did not,” Ms. Huang, the guardian, said.

The hospital declined to discuss the case, citing patient confidentiality. Mr. Menkes said, “We are not going to force people back” to their homelands.

Whether, as a person declared incapacitated by the court, Mr. Yu possesses the ability to consent to a repatriation remains to be seen. Ms. Huang said the case lay on ground ungoverned by guidelines, where hospitals are neither required to nor prohibited from doing anything with such patients.

“My position is that I need to look out for what is in his best interest,” Ms. Huang said.

After the September hearing, The Times contacted Mr. Yu’s 30-year-old son in Ningbo, China. The son, Cheng Jun Yu, said he and his mother had been estranged from Mr. Yu since he left for the United States. “The family situation wasn’t merry,” the son said.

“We do not wish for him to return,” he continued. “He will be a burden for me, and I do not have the time or resources to care for him. My mother has established a new family, and I do not wish for this matter to disrupt her life. If they want to send him back, they will have to negotiate with the Chinese government to see if the government will care for him.”

Into the Unknown

Hospitals say the federal government ignores the burden posed by these patients. In fact, Immigration and Customs Enforcement does not assume any responsibility for the health care of illegal immigrants unless they are in federal immigration detention, said a spokeswoman, Kelly Nantel, and it does not get involved in repatriations undertaken by hospitals.

For some hospitals, such repatriations are routine, for others a last resort. And, just as some forcibly repatriate patients, others do so only with consent — although consent is a murky concept when patients are told they have no alternative. While some hospitals pay for an immigrant’s repatriation and for their care in their homelands; others never make any inquiries into how deported patients have fared.

“We don’t do any follow-up,” said Sister McBride at St. Joseph’s in Phoenix.

Even patients at hospitals that never repatriate immigrants can find themselves embroiled in discharge plans of considerable complexity, as the case of Darwin Castro demonstrates.

One day last May, Mr. Castro, a 21-year-old illegal immigrant from Honduras, was getting a ride home from his construction job in Oklahoma City when the driver crashed into a tree. By the time he arrived at the Oklahoma University hospital, he was in shock from extreme blood loss and rushed into an operating room for surgery on a badly wounded liver. He also suffered a traumatic brain injury, facial and arm cuts and a broken hand.

Alerted by Honduran friends to the accident, Mr. Castro’s cousin, Wilmer Ubener Reaños, 25, called the hospital from New Orleans, where he too worked in construction. Mr. Reaños asked a bilingual colleague for help in communicating with the hospital. From that point forward, the colleague, David Ruiz, became the family liaison, and the hospital believed that David — listed in the records with no last name — was the patient’s cousin.

After six weeks, Mr. Castro was ready for discharge, said Allen Poston, the hospital spokesman. With a feeding tube and bladder catheter, Mr. Castro needed round-the-clock care but the hospital failed to find him a charity bed in a nursing home. Since it never repatriates patients, the only other option was to discharge Mr. Castro to his relative in New Orleans, Mr. Poston said.

In this case, though, the relative was an illegal immigrant who worked a 12-hour day and shared a room in a boarding house with another laborer. The hospital, Mr. Reaños said, had no idea where it was sending Mr. Castro. And Mr. Reaños had no idea what delicate condition his cousin was in, that he was barely ambulatory, brain-injured and could not talk, he said.

An air ambulance flew Mr. Castro to New Orleans and delivered him to David Ruiz. Several hours later, when Mr. Reaños got off work and arrived to pick him up, he found Mr. Castro sitting in his own waste in a wheelchair, groggy and unresponsive.

“He was so dirty,” he said. “I cleaned him. I changed his diaper. But that was all I could do. I did not know how to feed him, how to open the tube. I felt like they left me completely in the lurch. All I could do was cry.”

Mr. Reaños later learned that the transport company had trained Mr. Ruiz to use the medical equipment but Mr. Ruiz had not understood the instructions.

After two days, Mr. Castro appeared “on the verge of death,” Mr. Reaños said. He called an ambulance, and the cost of Mr. Castro’s care was thus shifted from Oklahoma to Louisiana, where a New Orleans hospital taught Mr. Reaños how to take care of him.

That proved arduous. Mr. Castro could not be left alone. Although his cousin assembled a patchwork community of caretakers, he missed so much work that he lost his job. Then his landlady kicked him out because his cousin “smelled sick,” he said.

At wit’s end, Mr. Reaños made plans to repatriate his cousin himself. He raised the money for a single ticket, but not enough for an escort. Through the Honduran consul, he arranged for a flight attendant to look after his cousin en route. But that arrangement disintegrated during a change of planes in Houston. When Mr. Castro did not arrive as scheduled in Honduras, his cousin furiously worked the phones, eventually discovering that Mr. Castro had been abandoned in the Houston airport. It took several more days for him to get back to his homeland.

By the time Mr. Castro arrived on Aug. 4, his suitcase, medical records and wheelchair had been lost in transit. He was exhausted, incoherent and too weak to stand, his aunt, Nolvia Rodríguez, said. But she took him into her modest home, and Mr. Castro has improved, Ms. Rodríguez said. A nurse in the neighborhood is helping out, and a clinic is tending to his medical issues when the family, which does not have a car, scrounges together the money to get him to the city.

To Mexico and Back

Antonio Torres’s journey through the American — and Mexican — health care systems began at dawn on June 7, when the 19-year-old, driving to work across a rutted, gravelly dirt road on the ranch where his family lives, flipped his pick-up truck. He was found, unconscious, about 150 feet from his vehicle by a ranch hand.

For two decades, his father, Jesús, a legal immigrant, had lived on both sides of the border, harvesting the fields of Arizona while traveling regularly to visit his family in northern Mexico. Last year, his wife, Gloria, and their four children received their green cards and joined him in a farmworkers’ community outside Gila Bend.

That June morning, the Torreses followed behind an ambulance that took Antonio to St. Joseph’s, the flagship hospital of Catholic Healthcare West, where he was admitted to the intensive care unit with a severe traumatic brain injury, bruised lungs and abdominal injuries. Two days later, his parents, “frozen with fear,” the elder Mr. Torres said, were unprepared for a hospital social worker’s frank assessment of their son’s prognosis.

“She said there was no hope for our son and that it would be best to unplug him,” Mr. Torres said. “She said, ‘You have to think what kind of life this is, hooked up to a ventilator. And if he wakes up, he will not be able to do much.’ When we said, ‘No!’ the social worker said that, well, then, without insurance, they couldn’t keep him.”

According to the social worker’s notes, the hospital anticipated that the patient would need long-term ventilator care and that, as a legal immigrant with less than five years in this country, he would not qualify for Arizona’s Medicaid coverage.

Five days after the accident, the social worker, using an interpreter, called the public hospital in Mexicali to arrange Antonio Torres’s repatriation. “Patient accepted for admission,” her notes say.

The following day, the notes add, “Parents upset.”

During that time, the elder Mr. Torres contacted Tom Espinoza, a Hispanic leader in Phoenix who had been battling the hospital’s repatriation of another comatose legal immigrant. Accompanying them to a meeting at the hospital, Mr. Espinoza, president of the Raza Development Fund, pledged to raise money for Antonio Torres’s care.

“Picture this,” he said. “It’s probably in a six-by-eight room. The social worker says, ‘Gee, that would be like taking money and throwing it down a black hole because this kid is going to die.’ I’ve got Mom and Dad crying, and she says that other patients would be better suited for that kind of investment.”

“At the end of the day,” Mr. Espinoza continued, “I realized it was not about the dignity of a person, it was about a bottom line.”

The hospital delayed the repatriation for a few days, giving the elder Mr. Torres time to search for a nursing home. He came up empty, so the hospital moved to repatriate his son even though he was not only comatose and dependent on a ventilator but also had a very high white blood cell count, indicating infection.

Two days later, early on June 20, his white blood cell count was still too high to meet the physician’s condition for transfer, according to the social worker’s notes. Nonetheless, a few hours later, with the same physician’s consent, Antonio Torres was placed on a portable ventilator for his departure.

Sister McBride said St. Joseph patients were transferred to Mexico during “a window of time” when they are stable but “still acute” because Mexican hospitals did not want them “down the phase of recovery.”

But Dr. Caleb Cienfuegos, director of the public hospital in Mexicali, said, referring to the younger Mr. Torres, “I personally would not have transferred the patient in that state.”

Accompanied by his mother, Mr. Torres traveled by ambulance to Calexico, Calif., a four-hour drive; his father, and reporters from La Voz, a Spanish-language weekly published by Mr. Espinoza’s wife, accompanied them in cars. At the border, Mr. Torres was wheeled from the air-conditioned American ambulance to a sweltering, World War II-era Mexican Red Cross vehicle.

The Torreses said that officials from St. Joseph’s told them that the Hospital General in Mexicali had a room waiting for their son. The social worker’s notes indicate that, through an interpreter, she had four conversations with a Dr. Dueñas, chief of the emergency room; the notes refer to him twice as “Dr. Urgencias,” or Dr. Emergency.

Interviewed at the bustling Mexicali hospital in early September, Dr. Mario Dueñas said that he did not recall the conversations. “But I would say the same thing to anybody: that my emergency room is open and ready for any patient from anywhere,” he said. “I cannot promise anyone a bed.”

The hospital director, Dr. Cienfuegos, said American hospitals generally made formal arrangements with him directly and not with his emergency room.

Both doctors were surprised to learn that the patient was a legal resident of the United States. “Generally, they send us the undocumented, the ‘wetbacks,’ ” Dr. Dueñas said.

Antonio Torres spent several days in the emergency room before a bed opened up in a crowded ward. His parents said Mexican doctors advised them to take their son back to the United States if possible. Through their church, the Jehovah’s Witnesses, the parents made contact with a church leader in El Centro, Calif., who took them under his wing, introduced them to the local hospital and raised money for “the best ambulances in the border area,” the elder Mr. Torres said.

Within a week, his son was on his way back to the United States, where the El Centro hospital was waiting to take him in and write off his care as charity.

“Our mission here is to provide health care access to our community,” Mr. Green, president of the city-owned hospital, said, “and anyone who comes to our E.R. is considered part of our community.

“This was a kid who came to this country legally, worked here legally and had an accident,” he continued. “For God’s sake, don’t we take care of our folk? To me, this case shows one of the disastrously broken pieces of our health care system.”

Mr. Torres arrived from Mexico in septic shock, a potentially fatal condition caused by overwhelming infection. After 18 days at El Centro, he woke forcefully from his coma. “They took out his trach tube, he cleared his throat and said, ‘Where’s my mom?’ ” his father said. “We cried with surprise. We cried with joy. You could have paddled away on our tears. Then, after that, he improved every day. He didn’t take baby steps. He jumped. He leaped.”

Told of the progress that the younger Mr. Torres had made, Sister McBride said, “That’s wonderful,” adding that she thought it testament to the emergency care at her hospital. “Maybe if he had been in a different setting, he may not have survived,” she said.

The Torreses have filed a detailed complaint against St. Joseph’s with the Arizona health department, and the matter is under investigation.

Mr. Torres, an Arizona taxpayer who did not qualify for his state’s Medicaid program, ended up qualifying for California’s simply because his parents had established residency by renting an apartment in El Centro on the advice of their Jehovah’s Witness friend. That enabled the hospital there to transfer him after a month to an intensive rehabilitation program in San Diego, which discharged him at summer’s end.

Now Mr. Torres walks with a cane and speaks slurred but comprehensible Spanish. He is itching to climb back onto a combine and cut alfalfa alongside his father. For the moment, though, he is commuting with his mother from Arizona to California for therapy.

In September, as he waited for his first session, he reached slowly into his pocket, pulled out his wallet and removed a picture of himself as a toddler. “Dangerous child,” his father said teasingly, and Mr. Torres flashed his lopsided smile.

Back in Arizona, Mr. Torres sat stolidly for hours on a worn couch in the concrete barracks-style housing where his family lives, letting the conversation swirl around him. Sitting beside him, a younger cousin held his hand, and toyed with a slingshot. His teenage sister wandered in and out with girlfriends. Crickets chirped loudly as a pinkish dusk settled on the dusty landscape outside.